Topical corticosteroid offers effective intervention

Key Points

"[Loteprednol etabonate] is the only topical corticosteroid approved specifically for use in treating the signs and symptoms of seasonal allergic conjunctivitis. This structurally unique ester-corticosteroid has a well-established record of efficacy and safety based on experience in clinical trials and clinical practice," said Dr. Parekh, managing partner, Brar-Parekh Eye Associates, Woodland Park/Edison, NJ, and clinical assistant professor of ophthalmology, The New York Eye and Ear Infirmary.

"I feel very comfortable prescribing a short course of loteprednol etabonate 0.2% when patients require potent action and fast relief of their ocular allergy signs and symptoms," he said, "and even over a longer course in patients who need ongoing control for allergic conjunctivitis refractory to other pharmacotherapeutic options."

A 30-year-old female, engineering professional who presented at the beginning of the spring allergy season represents a typical patient who may be started on loteprednol etabonate for management of seasonal allergic conjunctivitis. The patient has nasal polyps, rhinitis, and a history of asthma and pollen allergy. Although she is instructed annually about measures for minimizing allergen exposure and has been prescribed topical medications with combination antihistamine/mast cell stabilizing properties to control her ocular allergy, she is generally noncompliant with the advice until she becomes very symptomatic.

The patient is an avid golfer and presented with complaints of blurry vision, severe itchy eyes, and intermittent foreign-body sensation. Ocular examination revealed moderate conjunctival hyperemia, impressive papillary reaction, and discharge consistent with exacerbation of her seasonal allergic conjunctivitis.

"As a corticosteroid, loteprednol targets both the early and late phases of the allergic reaction by acting on multiple pathways. Starting this patient on loteprednol etabonate 0.2% 3 or 4 times a day will provide effective symptomatic control within a few days and is very well-tolerated in patients with irritated eyes because its glycerin-containing, slightly viscous vehicle is soothing on instillation," said Dr. Parekh.

The topical corticosteroid is generally combined with refrigerated artificial tears, which provide added comfort and help clear allergens from the ocular surface, and depending on the disease severity, perhaps with a multimodal over-the-counter or prescription topical anti-allergy product. Patients are followed for therapeutic response. Often, the corticosteroid can be tapered after just a few weeks and the patient transitioned to use of a combination anti-allergy product alone. However, loteprednol etabonate 0.2% may be re-initiated as rescue therapy if needed or maintained for longer-term use.

Although loteprednol etabonate 0.2% is not indicated for controlling perennial allergic conjunctivitis, Dr. Parekh noted he would use it in a similar approach to manage patients with more moderate to severe symptoms.

"Since these individuals may require longer-term therapy," Dr. Parekh said, "the fact that loteprednol has a more favorable safety profile than other topical corticosteroids increases my comfort level. Unlike any other topical ophthalmic corticosteroid, loteprednol etabonate only becomes activated when bound to receptor and then undergoes rapid inactivation to minimize steroid-related adverse events.

"While risks of secondary cataract formation and ocular hypertension are lower with loteprednol compared with other topical corticosteroids, periodic monitoring is still important in patients requiring more chronic treatment for disease control."

The fact that loteprednol etabonate 0.2% is available in a relatively large 10-cc bottle also makes it a good choice from an economical perspective for these patients, he added.

Managing severe episodes

When patients experience a more severe flare of their ocular allergy and present in significant distress with very red, chemotic eyes, Dr. Parekh said he might initiate treatment with loteprednol etabonate 0.5% (Lotemax, Bausch & Lomb). As disease control is achieved, he might transition to the 0.2% formulation and then continue with the topical corticosteroid as needed, or use other non-steroidal options.

All patients with allergic conjunctivitis are also counseled about personal hygiene and environmental strategies for minimizing allergen exposure. These include staying indoors when pollen counts are at peak levels, using air conditioning, HEPA-filters and dehumidifiers, washing hands frequently, and avoiding rubbing their eyes.

"Patients must understand that effective management of ocular allergy involves not only the use of topical medications to control their signs and symptoms, but also prophylactic measures," Dr. Parekh said.

He added that successful care of allergy patients could also be a practice-builder because many of these patients have either been ignored previously or attempted short-term self-treatment with over-the-counter remedies.

"Providing effective interventions for the ocular allergy patient positions the eye-care practitioner as the specialist who can treat the disease and truly brings in more patient referrals," said Dr. Parekh.

FYI

Jai G. Parekh, MD, MBA
E-mail: kerajai@gmail.com

Dr. Parekh is a speaker for Bausch & Lomb, Inspire, Ista, and Allergan Pharmaceuticals.